                    <div id="register_block">
                        <div id="block_head_blank" class="banner_block_head scroll_to">
			    <?php echo $block_title; ?>
                        </div>
                        
                        <div id="register_block_body">
			    <div id="register_step2">
				<form action="<?php echo base_url(); ?>paid-form/send" method="post" accept-charset="utf-8" class="email" id="banner_form">
				    <div>
					<span for="firstname"><?php echo $this->lang->line('firstname'); ?> : </span>
					<input type="text" name="firstname" id="firstname" class="input_text_search" value="<?php echo $firstname; ?>" />
				    </div>
				    <div>
					<span for="lastname"><?php echo $this->lang->line('lastname'); ?> : </span>
					<input type="text" name="lastname" id="lastname" class="input_text_search" value="<?php echo $lastname; ?>" />
				    </div>
				    <div>
					<span for="email"><?php echo $this->lang->line('email'); ?> : </span>
					<input type="text" name="email" id="email" readonly="readonly" class="input_text_search" value="<?php echo $email; ?>" />
				    </div>
				    <div>
					<span for="member_tel"><?php echo $this->lang->line('tel'); ?> : </span>
					<input type="text" name="tel" id="tel" class="input_text_search" value="<?php echo $tel; ?>" />
				    </div>
				    <div>
					<span for="subject"><?php echo $this->lang->line('subject'); ?> : </span>
					<select name="subject" class = "input" style="width:251px;">
					    <option value="<?php echo $this->lang->line('banner_paid_subject'); ?>"><?php echo $this->lang->line('banner_paid_subject'); ?></option>
					    <option value="<?php echo $this->lang->line('gold_paid_subject'); ?>"><?php echo $this->lang->line('gold_paid_subject'); ?></option>
					</select>
				    </div>
				    <div>
					<span for="detail"><?php echo $this->lang->line('detail'); ?> : </span>
					<textarea name="detail" id="detail" style="width:351px;height:250px;"></textarea>
				    </div>
				    <div>
					<span for="mysubmit">&nbsp;</span>
					<input type="submit" name="mysubmit"  id="mysubmit" value="Submit"  />
				    </div>
				</form>	
				<div>
				    <!--<input type="submit" name="mysubmit"  id="mysubmit" value="Submit"  />-->
				</div>
			    </div>
                        </div>
                        
                        <div id="register_block_footer">
                            
                        </div>
                    </div>
		    <script type="text/javascript" src="<?php echo js_asset_url('jquery.validate.min.js'); ?>"></script>
		    <script type="text/javascript" src="<?php echo js_asset_url('paid_form.js'); ?>"></script>